Nursing documentation: nonphysical dimensions of end-of-life care in acute wards

Aim To explore discrepancies between nurses' knowledge and their documentation of issues of psychosocial, spiritual and cultural aspects of palliative care, evidenced clearly in recent nursing research into end-of-life care in an acute care, teaching hospital. Design The study involved a retrospective patient case-note audit of an opportunistic sample of 20 patients deceased recently and interviews of the two nurses most involved in the care of each patient (n=40). Findings This research indicates that nurses in acute care settings often recognize, sometimes explore, but infrequently document psychosocial, spiritual and cultural aspects of care. Conclusion There is a strong need for: (1) education about both the impact of non-physical dimensions of patients' lives and the effective documentation of these dimensions; and (2) up-grading of documentation tools to better facilitate documentation of non-physical aspects of palliative care.